If you are like me, you enjoy all the wonderful things that winter brings, sledding, building snow persons, skiing, drinking hot cocoa, etc. There is one thing that we really don’t take into consideration when cold weather presents itself – carbon monoxide.  The human body is an incredible thing and can endure great stress through the winter, however, this may come as a shock to most of you, the body is unable to endure extremes of temperature for extended periods of time. A solution to the inconvenience of the cold is necessary, and that comes in the form of preventing heat loss (ie clothing, gloves) and heating the environment in which we are present (furnace, radiator, gas heater). Unfortunately, heating our environment can lead to unintended exposure to a very deadly toxin: carbon monoxide.

What is carbon monoxide (CO) exactly? It is a gas that is invisible and odorless to humans. This is not to be confused with hydrogen sulfide, a deadly gas that smells like rotten eggs. Carbon monoxide is a byproduct of incomplete fuel combustion and is often emitted from household items such as vehicle exhaust, ovens, inadequately serviced home furnaces, space heaters, and small gas engines that you find in-home generators, snowblowers, and lawnmowers. In studies, people are most likely to have their unintended CO exposure while at home.

Why is carbon monoxide so deadly? Hemoglobin is the molecular structure in our red blood cells that carries oxygen molecules. When we breathe in carbon monoxide they attach to the hemoglobin just like oxygen does. Unlike oxygen, however, carbon monoxide provides no benefit to our body’s tissues. In addition to this, the carbon monoxide molecules essentially “stay put” and do not let oxygen reattach to the hemoglobin. This leads to our red blood cells carrying less oxygen to our tissues (brain, heart, muscles, etc.). How long can you hold your breath? It’s a bit more complicated than this hypothetical question, but you get the idea: our body needs a constant supply of oxygen for survival.

Carbon monoxide exposures account for tens of thousands of Emergency Department visits annually, with thousands being hospitalized for significant exposures. Persons under the age of 44 make up the majority of these visits, but older patients make up larger percentiles of persons requiring admission to the hospital. We are at an increased risk of its exposure here in New England, as persons that live in colder parts of the country often have higher risk activities that lead to exposure.

What can I do to prevent CO exposure to myself and my family?

• Step number one is to ensure you have working carbon monoxide detectors on every floor of your home. Check each year that they are in working condition. These can be picked up at hardware stores anywhere.
• Having your home heating system serviced annually if they utilize natural gas, coal, or oil/fuel. According to the CDC, these account for the 2nd greatest number of unintended CO exposures.
• NEVER run an internal combustion car in your garage with the door closed. Keep in mind that even with the garage doors open fumes including CO may still enter your home.
• Do not place your fuel combustion generators in your garage or abutting your home, regardless of whether you have the garage door open or not. Per the CDC statistics, fuel-burning generators are the number one reason for unintended CO exposures. Consumer Report recommends always placing your generator 20 feet or more from your home, with the exhaust facing away from the home.
• Ensure your chimney is free of buildup or debris.
• NEVER use a fuel-burning grill indoors for cooking, and do not use your oven for heating your home.

What symptoms could I have if I have a carbon monoxide exposure?

They can be vague, but may include:

• Headache, dizziness, confusion
• Nausea, vomiting
• Rapid heart rate, chest pain, shortness of breath
• In severe exposures you can, unfortunately, have a heart attack, seizure, coma, or even die
• Some persons may exhibit “cherry red” lips, but this is not a common finding, nor is it necessary for diagnosis

What should I do if I suspect a carbon monoxide environment is present or my CO detector is going off?

• Gather all family members in your home (including pets), leave your home and IMMEDIATELY CALL 911.
• Pets, lending to their smaller body size, as well as children will often have symptoms before adults, but this is not foolproof.
• Your local Fire Department with evaluating the home (or business) for CO elevations utilizing specialized equipment. If your family has had an exposure, they may recommend evaluation at your nearest Emergency Department.

What do the Emergency Medical Services team and the Emergency Department do to treat CO exposure?

• Whether suspected or a confirmed exposure we often start with supplemental oxygen therapy, ie nonrebreather oxygen mask. Saturating your blood with supplemental oxygen will help displace the carbon monoxide molecules off of the hemoglobin faster, allowing your red blood cells to carry oxygen again to your body’s tissues.
• We may check blood work, including a test where we can see what the actual saturation of carbon monoxide is in your blood. Other tests we may perform look for evidence of organ damage as a result of a lack of oxygen reaching our tissues. We may also perform an ECG of your heart if you are having any signs or symptoms the CO exposure is affecting your heart.
• If you are very ill, we may consider a therapy called Hyperbaric Oxygen Therapy. This treatment involves you sitting in a comfortable chamber where pressure is increased around you, thus speeding the CO molecules’ displacement even faster. Many cases will not require this therapy. Fortunately, there is one treatment center in Rhode Island: Kent Hospital. Kent Wound Recovery and Hyperbaric Medicine program has been in place for over a decade now and is the only emergent hyperbaric program in Rhode Island. In fact, there are only 2 emergent hyperbaric medicine treatment centers in all of New England, the other being Mass Eye and Ear in Boston. Both Kent and Mass Eye and Ear take turns for emergent hyperbaric coverage for the whole of New England.

In conclusion, carbon monoxide is a deadly gas that we most often encounter at home. Our lifestyle in the Northeast United States often puts us at an increased risk of exposure. It is for this reason that we must be aware of the dangers it possesses to us and our family. Fortunately, exposure is often preventable if we follow the well-established safety guidelines (CDC). Stay safe out there this winter!

Vincent Varamo, DO, is a board-certified Emergency Medicine Physician at Kent Hospital, an academic teaching institution in Warwick, RI. He has a special interest in EMS and toxicology.